10 Key Questions About Menopause

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Menopause is the period in women's lives when they stop menstruating. It is a normal, natural event – one that all women who reach midlife eventually go through. As women age, their ovaries produce lower levels of the sex hormones estrogen and progesterone. Eventually, this causes fertility as well as menstrual bleeding to end. Menopause is confirmed when a woman has not had a period for 12 consecutive months and there is no other obvious cause, such as illness.

There are different types of menopause and different stages:

"Natural" menopause occurs as part of normal aging. For women in the United States, it usually occurs at between the ages of 40 and 58.

"Induced" or "surgical" menopause is brought on by damage to or surgical removal of both ovaries (oophorectomy), often during treatment for medical conditions that can include cancer. This causes an abrupt end to hormone production and sudden onset of menopause, no matter what a woman's age. Women who have surgery to remove the uterus (hysterectomy) stop having menstrual periods, but they do not reach menopause unless both ovaries are also removed.

"Premature" menopause refers to menopause, whether natural or induced, that occurs before age 40.

"Perimenopause" is the transitional period leading up to menopause, when some women begin to notice changes in their periods and bodies. It can begin several years before menopause and lasts for a year after a woman's last period.

"Postmenopause" refers to the time in a woman's life after menopause.

Two factors appear to influence when a woman will reach menopause:

Genetics: Women often reach menopause around the same age as their mothers and sisters.

Smoking tobacco: Smokers go through menopause about two years earlier than nonsmokers.

What Are the Signs and Symptoms of Menopause?

Menopause, by definition, means a change in menstrual periods, so it makes sense that one of the first and most common signs women notice is a change in the pattern of their monthly menstrual cycles. The North American Menopause Society reports that about 90 percent of women experience changes in their menstrual cycles for four to eight years before actual menopause.

Menstrual cycles may become irregular.

Flow may be heavier or lighter than before.

Periods may last longer or become shorter.

These are all normal changes, but women should see their healthcare providers if they have:

Periods that come very close together

Heavy bleeding

Spotting (bleeding between periods)

Periods that last for more than a week

Some women notice no other signs of menopause until their menstrual periods stop. Because estrogen affects many parts of the body, when estrogen levels drop, the changes can affect many different aspects of a woman's life. Many, however, notice other changes in the years before menopause, often beginning around age 40, such as hot flashes, vaginal dryness, mood changes or trouble sleeping.

Are My Symptoms Due to Menopause or Something Else?

It's difficult to know when certain changes are due to a drop in hormones during the menopausal transition, general aging or a combination of the two factors. Similarly, many symptoms tend to worsen with stress or fatigue – two states women in midlife may find themselves in frequently. In many cases, the changes women experience are real, but there is not enough evidence to conclude that they are caused by menopause.

A panel convened in 2005 by the U.S. National Institutes of Health (NIH) divided reported symptoms into three categories:

Strongly or moderately linked to menopause:

Hot flashes and night sweats: Up to 80 percent of women have hot flashes or night sweats at some point during perimenopause and postmenopause. Other health issues can cause hot flashes, so if it seems unlikely they're connected to menopause, women should see their healthcare providers.

Vaginal dryness: Vaginal tissues become dryer and thinner, sometimes leading to pain during sex. Vaginal infections also may become more common.

Trouble sleeping: Some women may have trouble falling asleep or wake up too early.

Less evidence of a link to menopause:

Changes in mood: Some women report mood swings, irritability, anxiety, or depression during the menopausal transition. But because there are many potential causes for mood changes, it's difficult to say whether menopause causes any increase in these problems. Mood changes may be related to insufficient sleep – a symptom with stronger connections to menopause.

Insufficient evidence to establish a link to menopause:

Forgetfulness and trouble concentrating: Memory may seem to decline and it may be more difficult to focus, but there is too little information to establish a relationship between menopause and these symptoms, which may be due to the effects of aging or other causes.

Sexual problems: Vaginal dryness, which is linked to menopause, can make sex uncomfortable. But some women at menopause also report changes in desire, arousal and other aspects of sexuality. These changes have been associated with stress, personal relationships and socioeconomic conditions, but not to menopause.

Urinary incontinence: Results are mixed from a small number of studies, but so far there is not enough evidence to say that menopause causes incontinence.

Are There Other Health Concerns That Accompany Menopause?

There are some conditions associated with menopause and aging:

Heart disease and strokes: Before women reach the age of menopause, they have less heart disease and fewer heart attacks and strokes than men. But as women get older, their risk of heart disease and stroke rises.

For years, researchers have theorized that the decline in natural estrogen at menopause may play a role, and that replacing some estrogen with hormone supplements might offer women some protection. Results from recent studies, however, showed that healthy postmenopausal women who took hormones were actually at greater risk for heart disease than those who didn't take hormones.

Whether estrogen helps protect younger women from heart disease is still an open question. Many public health organizations do not recommend that women take hormones after menopause to reduce the risk of heart disease and stroke.

Osteoporosis: Lowered levels of estrogen at menopause are a major cause of the skeletal disorder osteoporosis, which causes bones to lose density and become weaker and more prone to fracture. While other factors contribute, the reduction of estrogen during menopause is the major cause of bone loss for postmenopausal women. Studies have shown that, in postmenopausal women, estrogen and estrogen combined with progestin (a synthetic form of progesterone) can increase bone density, prevent bone loss and prevent osteoporosis-related fractures in the hip and spine.

While some products that contain estrogen are approved for treatment of osteoporosis, potential problems with hormone replacement therapy have prompted the FDA to recommend that women at risk for the condition use medications without estrogen. The following drugs are FDA-approved for the prevention and treatment of osteoporosis in postmenopausal women:

Fosamax (alendronate), Boniva (ibandronate) and Actonel (risedronate) are bisphosphonates, drugs that reduce the activity of cells that cause bone loss.

Evista (raloxifene) is in a group of drugs called selective estrogen receptor modulators, or SERMS, that have some of the same effects on bone as estrogen.

How Are Severe Symptoms of Menopause Treated?

Just as the age of menopause varies, so do the number and severity of the symptoms women experience. Many women need no special treatment and can manage any uncomfortable symptoms by making behavior and lifestyle changes. But for others, symptoms are severe enough to require medical treatment.

In 2002, results from a large study raised questions about the safety of hormone replacement therapy. Healthy postmenopausal women who took hormones, the study found, had higher incidences of serious problems, such as:

The results also showed benefits from taking estrogen with progestin, including fewer hip fractures and less colon cancer. And systemic estrogen remains effective at reducing menopausal symptoms such as hot flashes, vaginal dryness and sleep disturbances.

Based on the study's results, the FDA noted that while hormone supplements relieve some symptoms of menopause in postmenopausal women, they carry serious risks. They should not be taken to prevent heart disease, the FDA says, and although they are effective in preventing postmenopausal osteoporosis, they should be considered only by women who cannot take medications that do not contain estrogen.

Despite the risks, some women who have severe hot flashes and other symptoms that seriously interfere with their lives consider using low doses of estrogen or estrogen with progestin for relatively short periods of time. Because this treatment seeks to relieve symptoms and not replace the full amount of a woman's hormones, many healthcare providers now call it menopausal hormone therapy (MHT).

The FDA recommends that women discuss the risks and benefits of MHT with their physicians. If you decide to use hormones, use the lowest dose possible for the shortest amount of time necessary to relieve symptoms. The FDA suggests women check with their doctors every three to six months to see if they still need the drugs.

What Products Are Available for Menopause Hormonal Therapy (MHT)?

Many different products in a wide variety of forms, dosages and formulations are available for women who decide to use MHT:

Some estrogens are derived from plants, such as soy and yams; others come from the urine of pregnant horses.

To decrease the risk of endometrial cancer that comes with the use of estrogen alone, estrogens along with progestin are prescribed for women who have a uterus. Women who no longer have a uterus usually take estrogen alone.

Estrogen can be delivered in pills, gels, creams, patches, injections and rings that are inserted into the vagina. Exactly which form is best depends on a woman's individual situation. In general, however, women who are using estrogen solely to ease vaginal dryness, itching or burning may benefit more from a product that is applied topically to the vagina.

There are two main forms of dosage for estrogen: systemic and local. Systemic forms – whether pills, patches, gels or injections – deliver estrogen throughout the blood to all parts of the body. Local forms, including most creams and rings that are applied to the vagina, affect mainly that part of the body, so less estrogen circulates in the bloodstream.

Custom-compounded, "bioidentical" or natural hormones

These terms often are used interchangeably to refer to custom-mixed preparations of hormones that attempt to match the hormones made by a woman's body. The compounds may or may not use ingredients that are approved by the FDA, such as estrogen and progestin, but the products themselves are not regulated by the agency. The North American Menopause Society points out that, so far, there is little if any scientific evidence about either their benefits or their risks.

Are There Any Non-Hormonal Treatments for Menopause?

Hormone therapy remains the most effective FDA-approved treatment for symptoms of menopause, but scientists have studied the use of other drugs to relieve the most common symptoms. Though not approved by the FDA for treatment of menopausal symptoms, drugs that have been studied include:

Dietary supplements and botanicals, products made from plants with potential therapeutic uses, may provide some relief for menopausal symptoms. There is little scientific evidence, however, to support their effectiveness. Some supplements and botanicals can interact with prescription medications, and different products vary in the type and amount of ingredients they contain. In addition, some may cause side effects. The National Institutes of Health (NIH) panel on treatments for menopause-related symptoms considered the effects of several botanicals:

Phytoestrogens: Plant chemicals similar in structure to estrogen, they may act like a weak form of the hormone in the body. The panel found some evidence that soy extracts containing phytoestrogens may help relieve hot flashes, but most studies of the effects of dietary soy did not show a benefit. Certain women should be especially careful about using phytoestrogens:

Those who have had or are at risk for conditions affected by hormones, including breast, uterine or ovarian cancer, and endometriosis or uterine fibroids.

Those taking drugs that increase estrogen levels in the body, such as birth control pills, MHT or the drugs called selective estrogen receptor modulators (SERMS).

Black cohosh: Results of studies evaluating this herb's effect on hot flashes and other menopausal symptoms are mixed so far; more studies are underway. Because it isn't known how it might affect breast tissue, women with breast cancer may want to avoid black cohosh.

Red clover: There is no consistent or conclusive evidence that red clover leaf extract reduces hot flashes. Studies in women show few side effects; animal studies, though, have raised concerns that red clover might adversely affect hormone-sensitive tissue in the breast and uterus.

Dong quai: The NIH panel did not find dong quai to be useful in reducing hot flashes. Dong quai is known to interact with the anticoagulant drug warfarin, which can lead to bleeding problems.

Ginseng: Ginseng may help with some menopausal symptoms, such as mood changes and sleep disturbances. It has not been found helpful for hot flashes.

Kava: Kava may decrease anxiety, but there is no evidence that it decreases hot flashes. More importantly, The FDA has issued a warning about kava because of its potential to damage the liver.

Is There Evidence That Lifestyle Changes Help Menopause Symptoms?

The NIH panel looked at three behavioral changes that might improve menopausal symptoms. They found that:

Exercise has improved quality of life for women with menopausal symptoms, but there is little evidence it affects hot flashes or vaginal dryness.

Paced respiration – taking slow, deep breaths in through the nose and out through the mouth – appeared in one small study to help with hot flashes.

Educating women about menopause and what they can do to help themselves improves their knowledge but seems not to affect their menopausal symptoms.

Though there is little research to prove effectiveness, women might try the following behavioral changes for certain symptoms, according to the North American Menopause Society:

Hot flashes: Identify and avoid hot flash "triggers," such as hot drinks, spicy foods, alcohol, caffeine or external sources of heat, such as hair dryers. Stay cool during the day, and try to stay cool at night by using a fan or air conditioner, putting a frozen cold pack under the pillow or sipping cool water.

Sleep problems: Avoid heavy evening meals and don't use products containing alcohol, caffeine or nicotine. Maintain a regular sleep schedule and keep the bedroom quiet, cool and dark. If you don't fall asleep within about 15 minutes of going to bed, leave the bedroom and do something else until you feel drowsy.

Where Can I Find More Information About Menopause?

You can find more information about living well with menopause at Everyday Health and from non-profit organizations such as those listed here:

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